By: Van de Putte S.B. No. 1313
A BILL TO BE ENTITLED
AN ACT
relating to balance billing by facility based physicians or
providers.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Article 20A.09, Insurance Code, as amended by
Chapter 837, Chapter 905 and Chapter 1023, Acts of the 75th
Legislature, Regular Session, 1997, is amended to read as follows:
(f) If medically necessary covered services are not
available through network physicians or providers, or if network
facilities provide or arrange to provide services to enrollees
through non-network physicians or providers, then the health
maintenance organization, on the request of a network physician or
provider, within a reasonable period, shall allow referral to a
non-network physician or provider and shall fully reimburse the
non-network physician or provider at the usual and customary or an
agreed rate. The network provider must ensure through contract,
indemnity or otherwise, that the enrollee is held harmless for the
payment of the cost of covered services provided by the non-network
physician or provider except for applicable copayments and
deductibles. The evidence of coverage must provide for a review by
a specialist of the same specialty or a similar specialty as the
type of physician or provider to whom a referral is requested before
the health maintenance organization may deny a referral.
SECTION 2. Article 20A.09, Insurance Code, as amended by
Chapter 163, Chapter 837, Chapter 1023 and Chapter 1026, Acts of the
75th Legislature, Regular Session, 1997, is amended to read as
follows:
(C) a provision that, if medically necessary covered
services are not available through network physicians or providers,
or if network facilities provide or arrange to provide services to
enrollees through non-network physicians or providers, then the
health maintenance organization must, on the request of a network
physician or provider, within a reasonable time period allow
referral to a non-network physician or provider and shall fully
reimburse the non-network physician or provider at the usual and
customary or an agreed rate. The network provider must ensure,
through contract, indemnity or otherwise, that the enrollee is held
harmless for the payment of the cost of covered services provided by
the non-network physician or provider except for applicable
copayments and deductibles; each contract must further provide for
a review by a specialist of the same or a similar specialty as the
physician or provider to whom a referral is requested before the
health maintenance organization may deny a referral;
SECTION 3. Article 20A.18A., Insurance Code, as amended by
Chapter 1026, Acts of the 75th Legislature, Regular Session, 1997,
is amended to read as follows:
(g) All contracts or other agreements between a health
maintenance organization and a physician or provider shall specify
that the physician or provider will hold an enrollee harmless for
payment of the cost of covered health care services in the event the
health maintenance organization fails to pay the provider for
health care services, and shall further specify that the provider
shall require its subcontracted physicians and providers to honor
such hold harmless agreement.
SECTION 4. Article 20A.18F, Insurance Code, as amended by
Chapter 550, Acts of the 77th Legislature, Regular Session, 2001,
is amended to read as follows:
(a) Each contract between a health maintenance organization
and a limited provider network or delegated entity must provide
that if medically necessary covered services are not available
through network physicians or providers, the limited provider
network or delegated entity must, on request of a network physician
or provider, allow a referral to a non-network physician or
provider and shall fully reimburse the non-network provider at the
usual and customary or an agreed-upon rate. All contracts or other
agreements between a health maintenance organization and a limited
provider network provider network or delegated entity shall specify
that the physician or provider who holds a contract with the limited
provider network or delegated entity shall hold an enrollee
harmless for payment of the cost of covered health care services in
the event the health maintenance organization fails to pay the
limited provider network or delegated entity for health care
services and shall further specify that the limited provider
network or delegated entity shall require its subcontracted
physicians and providers to honor such hold harmless agreement.
SECTION 5. Sec. 3, Article 3.70-3C, Insurance Code, as
added by Chapter 1024, Acts of the 75th Legislature, Regular
Session, 1997, is amended by adding Subparagraph (p) to read as
follows:
(p) A preferred provider contract between an insurer and a
preferred provider must contain a provision that states if the
preferred provider provides or arranges to provide services to
insureds through non-network physicians or providers, then the
preferred provider must ensure through contract, indemnity or
otherwise, that the insured is held harmless for the payment of the
cost of covered services provided by the non-network physician or
non-network provider except for applicable copayments, coinsurance
and deductibles.
SECTION 6. This Act takes effect immediately if it receives
a vote of two-thirds of all the members elected to each house, as
provided by Section 39, Article III, Texas Constitution. If this
Act does not receive the vote necessary for immediate effect, this
Act takes effect September 1, 2003.